Child & Parent Details

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Which location is managing your booking?
Address(Required)
e.g. another parent, health professional, google, social media, radio, billboard etc.

Health History

This information is collected to understand your child’s growth, development and health.
Health History(Required)
Please check any boxes that apply
If yes, please provide Specialist's name, Profession & name of practice
Any medications or supplements taken by your child?(Required)
Allergies?(Required)
Does your child experience any of the following conditions?(Required)
If your child does have allergies or other airway issues, have you consulted with any health professional?
Has your child had any surgery?(Required)
Does your child have any special needs we should be aware of?(Required)
Immunisations - Are they up to date?(Required)

Dental History

Is this your child's first visit to the dentist?(Required)
**Especially if any dental x-rays were previously taken, as Oral Health & Beyond will only take diagnostic images if clinically necessary.
What is the reason for your visit with us?(Required)
Has your child ever had an unfavourable dental visit?(Required)

How well does your child tolerate dental/medical care?(Required)
How many times a day is your child brushing their teeth?(Required)
Has your child ever had any dental x-rays taken?
If clinically required, dental x-rays are an important part of diagnosing your child's dental health. Oral Health & Beyond uses very low dose radiation equipment. This will be discussed if needed, as your consent is required.
Is there a history of dental decay or missing teeth in the family?

Oral Restrictions - Lip and Tongue Tie

Has your child ever been examined for oral restrictions of the oral muscles such as tongue/lip tie?
Has your child previously had a lip & or tongue released?

Diet & Feeding

As an infant, how was your child fed?
Did you experience issues feeding your child as an infant?

Did/does your child have any of the following issues with eating?
What does your child drink from?

Sleep & other developmental questions

Has your child ever experienced any of the following?(Required)
Bodywork - Has your child ever been assessed/treated by a Chiropractor, Bowen Therapist or the like?(Required)
Speech - Do you have any concerns in regards to your child's speech?(Required)
Has your child had any Speech Therapy?

Habits -Did or does your child have any of the following habits?
Developmental - Have you had any concerns in regards to your child's weight gain?
Is your child reaching milestones within anticipated time frames?

Acknowledgement

I submit this medical form on behalf of my child & I understand that this information is correct to the best of my knowledge. I understand it will be held strictest confidence and only used to improve the quality of service my child receives.
Financial acknowledgment(Required)
Acknowledgement - Photographs/Marketing(Required)
Photos are routinely taken for dental/myofunctional, research & education purposes and in most cases these are for your child's dental records & kept on file only. Oral Health & Beyond does sometimes takes fun photos for use on social media, but will always ask your permission. I understand that if photos of my child are used, first name may be used but all other identifying information will be kept confidential. I do not expect compensation, financial or otherwise for the use of images.
Name of Parent/Guardian(Required)
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